BACKGROUND: Transplant recipients in whom cutaneous squamous-cell carcinomas develop are at high risk for multiple subsequent skin cancers. Whether sirolimus is useful in the prevention of secondary skin cancer has not been assessed. METHODS: In this multicenter trial, we randomly assigned transplant recipients who were taking calcineurin inhibitors and had at least one cutaneous squamouscell carcinoma either to receive sirolimus as a substitute for calcineurin inhibitors (in 64 patients) or to maintain their initial treatment (in 56). The primary end point was survival free of squamous-cell carcinoma at 2 years. Secondary end points included the time until the onset of new squamous-cell carcinomas, occurrence of other skin tumors, graft function, and problems with sirolimus. RESULTS: Survival free of cutaneous squamous-cell carcinoma was significantly longer in the sirolimus group than in the calcineurin-inhibitor group. Overall, new squamous-cell carcinomas developed in 14 patients (22%) in the sirolimus group (6 after withdrawal of sirolimus) and in 22 (39%) in the calcineurin-inhibitor group (median time until onset, 15 vs. 7 months; P=0.02), with a relative risk in the sirolimus group of 0.56 (95% confidence interval, 0.32 to 0.98). There were 60 serious adverse events in the sirolimus group, as compared with 14 such events in the calcineurin-inhibitor group (average, 0.938 vs. 0.250). There were twice as many serious adverse events in patients who had been converted to sirolimus with rapid protocols as in those with progressive protocols. In the sirolimus group, 23% of patients discontinued the drug because of adverse events. Graft function remained stable in the two study groups. CONCLUSIONS: Switching from calcineurin inhibitors to sirolimus had an antitumoral effect among kidney-transplant recipients with previous squamous-cell carcinoma. These observations may have implications concerning immunosuppressive treatment of patients with cutaneous squamous-cell carcinomas. (Funded by Hospices Civils de Lyon and others; TUMORAPA ClinicalTrials.gov number, NCT00133887.).

oronavirus disease 2019 (COVID-19) is mainly characterized by fever and respiratory symptoms. 1 During this pandemic, several cases of unusual purplish red lesions on the feet and/or hands, mimicking chilblains, have been reported in the literature and on social media. Some researchers have suspected that these lesions are associated with asymptomatic or mildly symptomatic COVID-19. 2-7 However, to our knowledge, no study has proved a pathologic link between these skin lesions and COVID-19. This observational prospective case series aimed to investigate the possible association between chilblains and COVID-19. Methods Between April 10 and April 17, 2020, we enrolled 31 patients who visited the Department of Dermatology at Cliniques uni-versitaires Saint-Luc, Brussels, Belgium. All patients had purplish red chilblain lesions on toes and/or fingers, which had appeared between 1 and 30 days before consultation. The data from all study participants are summarized in the Table. The study and data collection were approved by the institutional review boards of Cliniques universitaires Saint-Luc and Université Catholique de Louvain. Written informed consent was obtained from all study participants. All patients underwent reverse transcriptase-polymerase chain reaction (RT-PCR) analysis by nasopharyngeal swab to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA when they presented for chilblains. In all patients, blood analyses included the following: liver function and renal function; tests for antinuclear antibodies, rheumatoid factor, CH50, C3, C4, antineutrophil cytoplasmic autoantibody, antistreptolysin O antibody, and cold agglutinins; prothrombin time and activate partial thromboplastin time; levels of D-dimer, an-IMPORTANCE During the coronavirus disease 2019 (COVID-19) pandemic, several cases of chilblains have been reported. OBJECTIVE To determine if chilblains are associated with COVID-19. DESIGN, SETTING, AND PARTICIPANTS This monocentric case series was conducted at the Department of Dermatology at Cliniques universitaires Saint-Luc, a tertiary care hospital in Brussels, Belgium, between April 10 and April 17, 2020. We evaluated a total of 31 referred patients who had recently developed chilblains. MAIN OUTCOMES AND MEASURES Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) was used to detect severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA on nasopharyngeal swabs for all patients and in skin biopsy specimens for 22 patients. Blood samples from all patients were tested for specific anti-SARS-CoV-2 immunoglobulin (Ig) M and IgG antibodies. All patients had extended blood analyses. Histologic (22 patients) and immunofluorescence examinations (15 patients) were performed on the skin biopsy specimens. RESULTS The 31 patients were generally in good health; most were teenagers or young adults, and 19 were women. Histopathologic analysis of skin biopsy specimens (22 patients) confirmed the diagnosis of chilblains and showed occasional lymphocytic or microthrombo...

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Importance: Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical.Objective: To determine the dermoscopy features of NM.Design: Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/ hypomelanotic or pigmented to assess outcomes.Setting: Predominantly hospital-based clinics from 5 continents.Main Outcome Measures: Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma.Results: Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, bluewhite veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (Ͼ98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM.Conclusions and Relevance: When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.